Turning 'grumpy old man' syndrome into a disease

Medical Matters:Do grumpy old men suffer from testosterone deficiency? According to some experts they do. They have even coined a medical sounding label – Irritable Male Syndrome (IMS) – to cover the range of symptoms thought to be caused by a drop in testosterone levels in males.

Sufferers aren’t just grumpy: they have mood swings, are anxious and have a lowered libido as well. And just in case the similarity with female hormone deficiency hasn’t hit home, men with the condition are also said to experience hot flushes.

So is there such a diagnosis as andropause, a mirror of the female menopause?

Steady decline

Andropause is not recognised by the World Health Organisation (WHO) in its ICD-10 classification of disease. One of the main arguments against it is that unlike women who have gone through the menopause, there is no complete shutting down of the male reproductive system.

Yes, testosterone levels do decline steadily with age but despite this some men retain the ability to father children. There is no evidence to suggest that men experience a sudden drop in hormone levels in the way women do.

Male hypogonadism, on the other hand, is a condition in which the levels of testosterone dip below the already reduced normal range in older men. It is characterised by sexual dysfunction, loss of muscle bulk, central obesity, fatigue, mood and sleep disturbances, osteoporosis and anaemia.

And while these features are associated with low serum testosterone concentration, not all men with a low serum testosterone are hypogonadal. Possibly the best piece of research in the field, the European Male Ageing Study (EMAS) found a prevalence of hypogonadism of 0.6 per cent in those aged 50-59, 3.2 per cent in those aged 60-69, and 5.1 per cent in men in their 70s.

So while it is entirely reasonable to prescribe testosterone replacement therapy (TRT) for a man diagnosed with hyogonadism, for many physicians serious questions remain about the appropriateness of offering the same treatment to an older man with “andropause”.

The evidence base for any benefit of TRT for these men is slim.

“Monkey glands”

It’s as if the entire “male menopause” concept has never really moved on from the “monkey glands” treatments of the 1920s and 1930s.

Pioneered by Dr Serge Voronoff in France, who came up with the idea after noting that eunuchs aged faster than men who had not been castrated, the surgical procedure was described thus: “The monkey testicle would be cut in pieces of about two centimetres long by a half centimetre wide and a few millimetres deep. The surgeon then introduces two grafts in the scrotum, which he fixes with stitches taken off after eight days.”

Pablo Picasso may have had the procedure. Players with English soccer team Wolverhampton Wanderers reputedly did at the behest of their manager; a few good seasons followed but the glands were rapidly rejected, suggesting a placebo effect at best.

The worry is that a relatively cavalier approach to testosterone therapy persists. Gels, patches and intramuscular injections of testosterone, prepared to the highest pharmaceutical standards, may have replaced the monkey gland lottery of yore but the prescribing patterns far exceed the EMAS percentages for the prevalence of hypogonadism. In one region in the UK, prescriptions for TRT have increased by 90 per cent in the past 10 years.

Simple phenomenon

Has a simple phenomenon of old age in the male been turned into a disease?

It wouldn’t be the first time a new “disease” had emerged to match an already available treatment. And it’s not without its risks, which may have been played down to those eager to experience an elixir of youth.

Just as HRT has been linked with breast cancer, the possibility that TRT might increase the risk of prostate cancer, in men already at an age associated with the highest prevalence of the disease, has not been ruled out.

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